EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT EASA. Annual Safety Review

Transcription

1 EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT EASA Annual Safety Review 2012

2 Overview of Key Facts 2012 Overview of the Number of Commercial Air Transport Accidents, Fatal Accidents and Fatalities for EASA MS Operated Aircraft Above 2,250 kg MTOM Aeroplanes Helicopters Period Number of Accidents Fatal Accidents Fatalities on Board Ground Fatalities Period Number of Accidents Fatal Accidents Fatalities on Board Ground Fatalities (Average per Year) (average) (Total) 2012 (Total) Number of Fatal Accidents Involving EASA MS and Third Country Operated CAT Aeroplanes, MTOM Above 2,250 kg, Number of Occurrences Fatal Accidents EASA MS Operators Fatal Accidents Third Country Operators Year EASA MS Operators 3-Year Average Third Country Operators 3-Year Average Number of Fatal Accidents involving EASA MS and Third Country Operated CAT Helicopters, MTOM Above 2,250 Kg, Number of Accidents Year EASA MS Non-EASA MS 3-year average EASA MS 3-year average Non-EASA MS

3 Proportion of Fatal Accidents by Aircraft Category Accidents in EASA MS Involving General Aviation Aircraft Below 2,250 kg MTOM, % 3% 2% 0% 0% Aeroplane Microlight 20% Glider Helicopter Gyroplane Other 42% Balloon Motorglider 27% Overview of the Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type All EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM Aircraft category Balloons Dirigibles Aeroplanes Gliders Gyroplanes Helicopters Microlights Other Motorgliders Period Total number of accidents Number of fatal accidents Number of fatalities on board Number of ground fatalities (average per year) (average per year) (average per year) (average per year) (average per year) (average per year) (average per year) (average per year) (average per year) Average Total Total Change (%) 2012 over previous -11% -8% -5% -58%

4 ISBN doi: /50178 ISSN Printed in Luxembourg

5 Annual Safety Review 2012 EUROPEAN AVIATION SAFETY AGENCY AGENCE EUROPÉENNE DE LA SÉCURITÉ AÉRIENNE EUROPÄISCHE AGENTUR FÜR FLUGSICHERHEIT

6 Annual Safety Review 2012 PAGE 2 Contents Executive Summary 4 Chapter 1 Introduction 8 Background... 9 Scope... 9 Content of the Review Chapter 2 Worldwide Aviation Safety 12 Chapter 3 Air Transport Statistics in EASA Member States 16 Introduction Flights in EASA MS Flight Information Regions Market Segments Flights Conducted by EASA Member States Registered Aircraft Movement of Passengers and Cargo Chapter 4 Commercial Air Transport 24 Introduction Aeroplanes Helicopters Balloons Chapter 5 Aerial Work 36 Introduction Aeroplane and Helicopter Accidents in Aerial Work Other Aircraft Types Chapter 6 General Aviation 42 Introduction Business Aviation Accidents General Aviation Accidents Above 2,250 kg MTOM General Aviation Accidents Below 2,250 kg MTOM Chapter 7 Aerodromes 54 Introduction Aerodrome Accidents and Serious Incidents Runway Excursions Ground Collisions Ramp Accidents and Serious Incidents Bird Strikes... 59

7 PAGE 3 Chapter 8 Air Traffic Management 62 Introduction Accidents Occurrences Occurrence Rates Chapter 9 European Central Repository 72 Introduction The ECR at a Glance Network of Analysts Occurrence Categories and Events in the ECR Chapter 10 Agency s Safety Actions 80 Chapter 11 Appendices 82 Appendix 1 Acronyms and Definitions Appendix 2 List of Figures and Tables Appendix 3 List of Fatal Accidents in Disclaimer The accident data presented is strictly for information purposes only. It is obtained from Agency databases comprised of data from ICAO, EASA Member States and the aviation industry. It reflects knowledge at the time the report was generated. Whilst every care has been taken in preparing the content of the report to avoid errors, the Agency makes no warranty as to the accuracy, completeness or currency of the content. The Agency shall not be liable for any kind of damages or other claims or demands incurred as a result of incorrect, insufficient or invalid data, or arising out of or in connection with the use, copying or display of the content, to the extent permitted by European and national laws. The information contained in the report should not be construed as legal advice. Acknowledgements The authors wish to acknowledge the contribution made by the Member States and to thank them for their support in the conduct of this work and in the preparation of this report. Photocredits Inside front cover (from left to right): Airbus SAS, Vasco Morao, Airbus SAS, Thales Alexis Frespuech, Vasco Morao, Daher Socata, Agusta Westland, Photopointcom THALES, DFS Deutsche Flugsicherung GmbH, Airbus SAS, Rolls Royce, Sikorsky/ Page 4: Vasco Morao/ Page 8: Agustawestland/ Page 12: Photopointcom THALES/ Page 16: Daher Socata/ Page 24: Airbus/ Page 36: Sykorsky/ Page 42: Vasco Morao/ Page 54: Airbus/ Page 62: DFS Deutsche Flugsicherung GmbH/ Page 72: Thales Alexis Frespuech/ Page 80: RollsRoyce/ Page 82: Airbus European Aviation Safety Agency, 2013 Reproduction is authorised provided the source is acknowledged.

8 Executive Summary PAGE 4

9 PAGE 5 The Annual Safety Review presents statistics on European and worldwide aviation safety. Data included in the Review comes from a variety of different sources, covering accident and serious incident data as well as contributions from National Aviation Authorities, Eurocontrol, EUROSTAT, Ascend and the ICAO Safety Indicators Study Group. The review covers the period , however where there is not enough data available the analysis is limited to The worldwide rate of fatal accidents for scheduled passenger and cargo flights has continued to decrease, providing a steady improvement in aviation safety. The rate of fatal accidents in EASA MS is comparable with and slightly lower than North America. There were 105 million IFR flights in the EASA Member States (MS) flight information regions in ten years. The number of flights in 2012 was 10.5 million, which is still less than the peak of 11.2 million flights per year in % of flights are traditional scheduled flights, 27% are low-cost scheduled flights and 6% are charter flights. In 2012, 925 million passengers and 14.5 million tonnes of cargo were carried in EASA MS. The number of Commercial Air Transport fatal accidents in 2012 was less than the 10-Year average. For Commercial Air Transport Aeroplanes between 2001 and 2010 there was an average of 25 accidents per year, including 3 fatal accidents per year. In 2012 there were 34 accidents, of which 1 was fatal. The fatality occurred when a ground operator was killed during aircraft loading. The most common type of accident is an abnormal runway contact while the most common type of fatal accident is a loss of control in flight. For Commercial Air Transport Helicopters between 2001 and 2010, there was an average of 13 accidents per year, including 3 fatal accidents per year. In 2012 there were 11 accidents, of which 2 were fatal. The most common type of accident is a loss of control in flight while the most common type of fatal accident is a controlled flight into terrain. The number of accidents involving General Aviation light aircraft has decreased by 10% compared with the previous five-year period. The number of fatal accidents decreased by 7%. However, exposure data for these aircraft is not available so it is not known whether there has been less general aviation activity as a result of the economic downturn and poor weather in 2012.

10 Annual Safety Review 2012 Executive Summary PAGE 6 Accidents and Serious Incidents relating to EASA MS aerodromes are becoming less common Commercial, ILS-equipped Aerodromes in EASA MS have had 15 accidents and serious incidents in the period where the aerodrome contributed to the occurrence in some way. The most common occurrence category to be assigned to an aerodrome accident or serious incident is runway excursion. There were 345 ATM-relevant accidents between 2008 and 2012 Air Traffic Management safety is analysed using data provided by Eurocontrol and collected as part of the Annual Summary Template mechanism. The most common types of occurrence (accidents, serious incidents and incidents) are Unauthorised Airspace Penetration and the rate of reported incidents has increased between 2003 and However, the number of serious and major incidents has remained stable, indicating that the overall increase relates to reporting. The European Central Repository is a centralised database of safety occurrences from all EASA MS. The amount of information in the ECR is increasing every year and the quality of data has improved significantly over the past 2 years. At the end of 2012 there were in total 664,149 occurrences in the ECR. Since 2009 the number of occurrences has begun to stabilise in the region of 100,000 to 120,000 occurrences per year.

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12 PAGE 8 1 Introduction

13 PAGE 9 Background Air transport is widely considered as one of the safest forms of travel. In Europe it is also one of the fastest growing. In order to continuously improve aviation safety in Europe, EASA and its stakeholders monitor aviation safety statistics to understand both the current situation and areas of possible improvement. This document provides a high-level overview of aviation safety statistics for Europe and worldwide. The Annual Safety Review is published by EASA to inform the public of the general safety level in the field of civil aviation. The Agency provides this review on an annual basis as required by Article 15(4) of Regulation (EC) No 216/2008 of the European Parliament and of the Council of 20 February EASA as an Agency is responsible for providing common standards of safety and environmental protection in civil aviation in Europe and worldwide. It is the centrepiece of regulations creating a single European market in the aviation industry. The Agency s responsibilities include: expert advice to the EU for drafting new legislation; implementing and monitoring safety rules, including inspections in the Member States; type-certification of aircraft and components, as well as the approval of organisations involved in the design, manufacture and maintenance of aeronautical products; authorisation of third-country (non EU) operators; safety analysis and research. The Agency s responsibilities are growing to meet the challenges of the fast-developing aviation sector. In the future, the Agency will also be responsible for safety regulations for airports and air traffic management systems. Scope The Annual Safety Review presents statistics on European and worldwide aviation safety. The statistics are grouped according to type of operation, such as commercial air transport or general aviation, and aircraft category, such as aeroplanes, helicopters or gliders. The data included in the Review comes from a variety of different sources: Accident and Serious Incident data for most aircraft categories comes from the database of the EASA Safety Analysis and Research Department. Aircraft data for aircraft below 2,250 kg MTOM was provided by EASA member states ATM data was provided by Eurocontrol, Air Transport Statistics were provided by Eurocontrol and by EUROSTAT, Exposure data for commercial air transport was provided by Ascend.

14 Annual Safety Review 2012 Introduction PAGE 10 As with all sources of information, the data is subject to slight changes over time as more information is added that may cause an accident or serious incident to be re-categorised. For this reason, the figures presented in the Annual Safety Review 2012 are likely to be slightly different to those presented in previous years. In this review, the terms Europe and EASA Member States (MS) are considered as the 27 EU Member States plus Iceland, Liechtenstein, Norway and Switzerland. For Commercial Air Transport operations the region is assigned based on the state of operator of the aircraft involved, while for all other types of operation the state of registry is used. The figures presented in the Review are high level and do not contain statistical tests. This is because the aim of the document is to provide a simple overview of the safety of aviation in Europe and worldwide, it is not intended as a complex technical document. However, the figures presented can be used as a reference and readers are invited to make use of the figures presented to apply their own tests and draw conclusions from these. Content of the Review The Annual Safety Review aims to cover all aspects of aviation that fall within EASA s remit. Consequently, the document has been divided into the following chapters: Worldwide Aviation Safety, Air Transport Statistics in EASA MS, Commercial Air Transport, Aerial Work, General Aviation, Aerodromes, Air Traffic Management, and European Central Repository. As with the previous version of the Review, specific information related to safety activities of the Agency is no longer provided. This information is now presented in the European Aviation Safety Plan (EASp), which can be found at: A list of acronyms and definitions can be found in Appendix 1. Appendix 2 provides a list of figures and tables and Appendix 3 provides a list of commercial air transport fatal accidents worldwide in 2012.

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16 PAGE 12 2 Worldwide Aviation Safety

17 PAGE 13 This chapter provides information on the worldwide fatal accident rate for aeroplanes with a maximum take-off mass above 2,250 kg, engaged in scheduled passenger or cargo operations. Acts of unlawful interference are not included in these figures. Figure 1 shows the number and rate per 10 million flights of passenger and cargo fatal accidents each year from 1993 to It can be seen that over the 20-year period there has been a significant reduction in the number and rate of fatal accidents. Figure 1: Number and Rate per 10 Million Flights of Scheduled Passenger and Cargo Fatal Accidents Worldwide per Year, Number of Fatal Accidents Rate per 10 Million Flights (three-year moving average) Year Passenger Cargo Rate per 10 million flights

18 Annual Safety Review 2012 Worldwide Aviation Safety PAGE 14 Figure 2 shows the fatal accident rate by region of the world, using the regions defined by the ECCAIRS taxonomy. Figure 2: Rate of Scheduled Passenger and Cargo Fatal Accidents, per 10 Million Flights by World Region, North America 2.1 EASA MS 2.0 Europe Non-EASA 21.7 Central America 8.1 South America 16.9 Africa 35.3 Middle East 14.3 Asia 4.8 Oceania 9.2

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20 PAGE 16 3 Air Transport Statistics in EASA Member States

21 PAGE 17 Introduction This chapter reviews air traffic, passengers carried and cargo transported in EASA Member States (MS). Air traffic data is sourced from Eurocontrol Statistics and Forecasts (STATFOR) and excludes Liechtenstein, which does not have a flight information region. Passenger and cargo data is sourced from EUROSTAT and is publicly available online. Timespans for the data presented vary due to the differing availability of the source data. Flights in EASA MS Flight Information Regions Between 2003 and 2012, there were approximately 105 million Instrument Flight Rules (IFR) flights in the EASA MS flight information regions. Figure 3 shows the number of flights per year. It can be seen that the number of flights per year has levelled off, following a decrease between 2008 and There were 10.5 million IFR flights in 2012, compared with 11.2 million in Figure 3: Number of IFR Flights in EASA MS per Year, Number of IFR Flights (millions) Year Market Segments The number of flights per year by market segment is shown in Figure 4 for the five year period of inclusive, covering low cost, scheduled and charter flights, but excluding other types of flight. Low cost flights have experienced some growth between 2008 and 2012, with 2.4 million flights in 2008 increasing to 2.6 million flights in 2012, an 11% increase. The proportion of flights in each sector is shown in Figure 5: 67% of flights are traditional scheduled flights, 27% are low-cost scheduled flights and 6% are charter flights.

22 Annual Safety Review 2012 Air Transport Statistics in EASA Member States PAGE 18 Figure 4: Number of IFR Flights in EASA MS per Year by Market Segment, Number of IFR Flights (millions) Year Scheduled Flights Low Cost Flights Charter Flights Figure 5: Proportion of Flights in Each Market Segment, % 27% Charter Flights Low Cost Flights Scheduled Flights 67%

23 PAGE 19 Flights Conducted by EASA Member States Registered Aircraft The types of aircraft filing a flight plan are recorded by the Eurocontrol Central Flow Management Unit and the data has been used below to show the number and types of EASA MS registered aircraft operating in European airspace. Figure 6: Number of EASA MS Registered Aircraft Filing Flight Plans, EASA MS Registered Aircraft Filing Flight Plans Year Figure 7: Number of EASA MS Registered Aircraft Filing Flight Plans by Aircraft Category, EASA MS Registered Aircraft Filing Flight Plans Unknown Aeroplanes Helicopters Others (Amphibian and Tiltwing) Aircraft Category

24 Annual Safety Review 2012 Air Transport Statistics in EASA Member States PAGE 20 Figure 8: Number of EASA MS Registered Aircraft Filing Flight Plans by Aircraft Mass Category, EASA MS Registered Aircraft Filing Flight Plans Unknown Below 2250 kg 2251 and 5700 kg 5701 and kg and kg Above kg Aircraft Mass Category Movement of Passengers and Cargo This section shows the number of passengers carried and amount of cargo transported in the EASA MS from 2008 to 2012, the data is sourced from EUROSTAT. Over the five year period approximately 4.4 billion passengers were carried in the EASA MS. The total number of passengers carried in the EASA MS per year is shown in Figure 9. Figure 9: Number of Passengers Carried Per Year in EASA MS, Number of Passengers Carried (million) Year

25 PAGE 21 The amount of cargo transported per year between 2008 and 2012 is shown in Figure 10. Over the five year period approximately 67.1 million tonnes of cargo was transported in EASA MS. Figure 10: Tonnes of Cargo Carried per Year in EASA MS, Tonnes of Cargo (millions) Year Maps showing the numbers of passengers carried and cargo transported in each EASA MS country for are shown in Figure 11 and Figure 12.

26 Annual Safety Review 2012 Air Transport Statistics in EASA Member States PAGE 22 Figure 11: Number of Passengers Carried per Country, Malta 0 10 (million passengers) > 800

27 PAGE 23 Figure 12: Tonnes of Cargo Transported per Country, Malta 0 10 (1000 tonnes) > 5000

28 PAGE 24 4 Commercial Air Transport

29 PAGE 25 Introduction The Commercial Air Transport (CAT) operations analysed in this chapter involve the transportation of passengers, cargo, mail for remuneration or hire and ferry/positioning flights. Aircraft accidents are aggregated by the State in which the aircraft operator was registered. Accidents and fatal accidents are identified as such using the definitions of ICAO Annex 13 Aircraft Accident and Incident Investigation. The first section of this chapter focusses on aeroplanes above 2,250 kg maximum take-off mass (MTOM), the second on helicopters, then the final section on balloons. Aeroplanes In 2012 there was a single fatal accident involving a EASA Member State (EASA MS) operated aircraft. This occurred in November 2012 when a ground operator became trapped between the baggage door of an Airbus A320 and a baggage loader during the boarding of an aircraft at Rome Fiumicino Airport. Table 1 shows that the number of fatal accidents and the number of fatalities in 2012 was below the average in the previous decade. The 34 accidents in 2012 represents a small increase compared to the 30 in 2011 and it is slightly higher than the average in the previous decade (25). In 2012, there were no onboard fatalities in accidents involving EASA MS operators. Table 1: Overview of Total Number of Accidents, Fatal Accidents and Fatalities for EASA MS Operated Aeroplanes, above 2,250 kg MTOM Period Number of Accidents Fatal Accidents Fatalities on Board Ground Fatalities (Average per Year) (Total) (Total) Figure 13 shows that the number of fatal accidents involving EASA MS operated aeroplanes has decreased over the past decade. There has been not been a year with more than one fatal accident involving an EASA MS operated aeroplane since For operators outside the EASA MS ( third country operators ) there has been a further reduction in fatal accidents from 37 in 2011 to 28 in 2012.

30 Annual Safety Review 2012 Commercial Air Transport PAGE 26 Figure 13: Number of Fatal Accidents in EASA MS and Third Country Operated CAT Aeroplanes, MTOM Above 2,250 kg, Number of Occurrences Year Fatal Accidents EASA MS Operators Fatal Accidents Third Country Operators EASA MS Operators 3-Year Average Third Country Operators 3-Year Average Figure 14 shows that the rates of fatal accidents for both EASA MS and third country operated aeroplanes has remained at the same level for the past 3 years. For EASA MS operators this shows that the historically low rate of fatal accidents has been maintained after the significant reduction between 2003 and The rates of fatal accidents are created by comparing the number of fatal accidents in scheduled passenger operations with the number of flights carried out. Figure 14: Rate of Fatal Accidents in EASA MS and Third Country Scheduled Passenger Operations, Aeroplanes Above 2,250 kg MTOM, Rate of Fatal Accidents Year EASA MS Operators 3-Year Average Third Country Operators 3-Year Average

31 PAGE 27 Fatal Accidents by Mass Category Figure 15 shows the distribution of fatal accidents by aircraft mass category for operators based in the EASA MS and for third country operators. For EASA MS operated aircraft it shows that 42% of the aircraft involved in fatal accidents were of a mass between 5,701 kg and 27,000 kg, 37% were between 27,001 kg and 272,000 kg, whilst 21% were between 2,251 and 5,700kg. The situation for third country operated aircraft is slightly different with the largest proportion, 40%, involving aircraft between 2,251 kg and 5,700kg. The majority of jet powered aircraft belong to the mass category between 27,001 kg and 272,000 kg. Smaller jet aircraft and most turboprop aircraft belong to the mass category between 5,701 kg and 27,000 kg, whilst light turboprop aircraft are generally found in the 2,251 kg to 5,700 kg mass category. Figure 15: Proportion of Fatal Accidents by Aircraft Mass Category, EASA MS Operated CAT Aeroplanes above 2,250 kg MTOM, EASA MS Operated 21% to kg 37% to kg to kg 42%

32 Annual Safety Review 2012 Commercial Air Transport PAGE 28 Figure 16: Proportion of Fatal Accidents by Aircraft Mass Category, Third Country Operated CAT Aeroplanes above 2,250 kg MTOM, Third Country Operated 2% 27% 40% to kg to kg to kg > kg 31% Accident Categories The assignment of an accident under a single or multiple occurrence category assists in the identification of particular safety issues. Accident categories were assigned to fatal and non-fatal accidents which involved EASA MS operated aeroplanes based on the definitions of the CAST-ICAO Common Taxonomy Team (CICTT). The CICTT have developed a common taxonomy for the classification of occurrences for accident and incident reporting systems. Further information about the categories used in this report can be found in Appendix 1: Definitions and Acronyms. An accident may have more than one category, depending on the circumstances contributing to the accident. Figure 17 provides details of the accident categories with the highest number of fatal and non-fatal accidents in the decade The highest number of fatal accidents, 7 in total, have been assigned the occurrence category Loss of Control - In Flight (LOC-I), which involves the momentary or total loss of control of the aircraft by the flight crew. This might be the result of reduced aircraft performance or because the aircraft was flown outside its capabilities for control. During the period , the number of fatal accidents (3) were the same for the categories System/ Component Failure - Non-Powerplant (SCF-NP), System/ Component Failure - Powerplant (SCF-PP), Unknown (UNK), Fire/ Smoke - Post Impact (F-POST) and Controlled Flight Into Terrain (CFIT). The highest number of non-fatal accidents involved the occurrence category Abnormal Runway Contact (ARC), which include long, fast or hard landings as well as the scraping of the tail or wing of the aircraft during take-off or landing.

33 PAGE 29 Figure 17: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS CAT Aeroplanes above 2,250 kg MTOM, RI-VAP LALT FUEL AMAN F-NI CABIN ATM USOS LOC-G WSTRW EVAC ADRM GCOL TURB ARC ICE BIRD MAC RE OTHR RAMP CFIT F-POST UNK SCF-PP SCF-NP LOC-I Number of Accidents Fatal Accidents Non-Fatal Accidents Helicopters The following section provides an overview of accidents in helicopter CAT operations. Unless otherwise noted, the presented data covers all mass categories. This is a change compared with the previous version of the Annual Safety Review, which only included aircraft above 2,250 kg MTOM. Table 2 shows that in 2012 there were 11 accidents, of which 2 were fatal, involving CAT helicopter operators from the EASA MS. Both numbers are below the decade average, though the total number of accidents is higher than the previous year. The number of fatalities is less than half than that of Table 2: Overview of Total Number of Accidents, Fatal Accidents and Fatalities for EASA MS Operated Helicopters, All Mass Categories Period Number of Accidents Fatal Accidents Fatalities on Board Ground Fatalities (average)

34 Annual Safety Review 2012 Commercial Air Transport PAGE 30 Figure 18 compares the number of fatal accidents involving helicopters with maximum take-off mass above 2,250 kg between operators in EASA MS and those in other regions (third country operators). EASA MS operators did not have any fatal accidents in For third country operators the number of fatal accidents in 2012 is equal to the 3-year average for the period Figure 18: Number of Fatal Accidents in EASA MS and Third Country Operated CAT Helicopters, Above 2,250 kg MTOM Number of Accidents Year EASA MS Non-EASA MS 3-year average EASA MS 3-year average Non-EASA MS Figure 19 shows the distribution of injuries sustained in CAT helicopter operations. In most accidents (44%) no injuries were sustained. Minor or serious injuries occurred in 31% of the accidents while 25% of the accidents had one or more fatalities. Figure 19: Proportion of Injury Levels for Accidents in EASA MS Operated CAT Helicopters, All Mass Categories, % 44% Fatal Serious Minor 20% None 11%

35 PAGE 31 Accidents by Operation Type Figure 20 shows the number of accidents by operation type in the period The category Passenger has been further broken down to HEMS, Air Taxi and Sightseeing. Conventional Passenger operations have the highest number of accidents in the 10 year period, closely followed by Helicopter Emergency Medical Services (HEMS) operations. Figure 20: Number of Accidents by Operation Type, EASA MS Operated CAT Helicopters, All Mass Categories, Number of Accidents Conventional Passenger Emergency Medical Service Air Taxi Ferry/positioning Sightseeing Cargo Unknown Operation Type Figure 21 shows the number of fatal accidents and the number of fatalities in off-shore operations and non offshore operations in the period % of the number of fatal accidents and 21% of the total number of fatalities happened in off-shore operations. In general, off-shore operations are carried out with large helicopters which, when an accident occurs, could give a larger number of casualties. So, although off-shore helicopters have experienced fewer fatal accidents and fatalities, the ratio of fatalities to fatal accidents is higher for this type of helicopter operation (8.67 fatalities per fatal accident) than for non-offshore operations (3.63 fatalities per fatal accident).

36 Annual Safety Review 2012 Commercial Air Transport PAGE 32 Figure 21: Proportion of Fatal Accidents and Fatalities in Off-Shore and Non Off-Shore Operations, EASA MS Operated CAT Helicopters, All Mass Categories, Fatal accidents 10% Off-Shore Non Off-Shore Fatalities 21% 90% 79% Accident Categories In order to assist in the identification of particular safety issues, one or multiple occurrence categories were assigned to helicopter accidents involving EASA MS operators. This was done using the CICTT occurrence categories, which are listed in Appendix 1. Figure 22 shows that the category with the highest number of accidents is Loss of Control - In Flight (LOC-I) followed by System/Component Failure or Malfunction Non-Powerplant (SCF-NP) and System/Component Failure or Malfunction Powerplant (SCF-PP). The category of SCF-NP includes accidents related to a malfunction of the gearbox. Accidents in the category Collision with Obstacles during Take-off and Landing (CTOL) include all accidents during take-off and landing where the main or tail rotor collided with objects on the ground. This category tends to apply to helicopters when the aircraft operate in confined areas close to obstacles. The highest number of fatal accidents involved the occurrence categories LOC-I, CFIT and LALT.

37 PAGE 33 Figure 22: Occurrence Categories for Fatal and Non-Fatal Accidents EASA MS Operated CAT Helicopters, All Mass Categories, USOS RAMP ICE GCOL EXTL AMAN ADRM FUEL LOC-G TURB ARC CTOL UIMC SEC MAC EVAC OTHR UNK WSTRW SCF-PP F-POST SCF-NP LALT CFIT LOC-I Number of Accidents Fatal Accidents Non-Fatal Accidents For the 5 occurrence categories with the highest total number of accidents, Figure 23 shows the number of accidents for light (MTOM 0-2,250 kg) and heavy (MTOM above 2,250 kg) helicopters. It is only in LOC-I that the number of accidents is higher for the light helicopters, in the other 4 categories there are a higher number of accidents with heavy helicopters.

38 Annual Safety Review 2012 Commercial Air Transport PAGE 34 Figure 23: Top 5 Occurrence Categories of Fatal and Non-Fatal Accidents in Helicopters Above and Below 2,250 kg MTOM, Number of Accidents kg > 2250 kg kg > 2250 kg kg > 2250 kg kg > 2250 kg kg > 2250 kg LOC-1: Loss of control - inflight CFIT: Controlled flight into or toward terrain SCF-NP: System/component failure or malfunction [non-powerplant] SCF-PP: powerplant failure or malfunction CTOL: Collision with obstacle (s) during take-off and landing Occurrence Categories - Mass Group Non-Fatal Fatal

39 PAGE 35 Balloons This section reviews CAT accidents involving balloons. Between 2008 and 2012, there were 54 balloon accidents. 4 accidents were fatal, of which 2 occurred in Figure 24 shows the number of accidents per year for balloon CAT. Figure 24: Number of Accidents Involving EASA MS Registered Balloon CAT, Number of Accidents Year

40 PAGE 36 5 Aerial Work

41 PAGE 37 Introduction This chapter discusses accidents which involved aircraft of all mass categories in Aerial Work operations. Aerial Work is an operation in which the aircraft is used for specialised services such as agriculture, construction, photography, surveying, observation and patrol, search and rescue, and aerial advertisement. The aircraft are identified using the state of registry of the aircraft and categorised as either an EASA Member State (MS) registered aircraft or third-country registered aircraft. Aeroplane and Helicopter Accidents in Aerial Work In Table 3 the time period presented extends from , showing the number of accidents in 2011 and 2012 as well as the average for the decade preceding these years. Table 3: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type, All Mass Categories, All EASA MS Registered Aerial Work Aircraft Aircraft category Period Number of all accidents Fatal accidents Fatalities on board Ground fatalities (average per year) Aeroplanes (average per year) Helicopters

42 Annual Safety Review 2012 Aerial Work PAGE 38 Figure 25: Fatal Accidents by Aircraft Category and Operation Type in Aerial Work, All Mass Categories, Aeroplanes Helicopters 13% 0% 13% 14% 23% 20% 12% 34% 12% 6% 9% 20% 12% 12% Fire fighting Agricultural Unknown Parachute drop Aerial patrol Photography Other Towing Aerial observation Other Agricultural Fire fighting Search and rescue Construction/sling load Figure 25 shows the distribution of fatal accidents by operation type between aeroplanes and helicopters for the decade 2003 to Accident Categories In order to assist in the identification of particular safety issues, one or multiple occurrence categories were assigned to accidents involving aeroplanes and helicopters conducting Aerial Work. This was done using the CICTT occurrence categories, which are listed in Appendix 1.

43 PAGE 39 Figure 26: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered Aerial Work Aeroplanes, RI-VAP ICE BIRD ADRM F-NI RAMP WSTRW USOS TURB EXTL GTOW LOC-G UIMC AMAN CTOL GCOL FUEL RE ARC SCF-NP OTHR SCF-PP CFIT UNK MAC F-POST LALT LOC-I Number of accidents Fatal accidents Non-Fatal accidents

44 Annual Safety Review 2012 Aerial Work PAGE 40 Figure 26 describes typical aeroplane accidents in Aerial Work. Loss of Control In-Flight (LOC-I) is the category with the highest number of fatal accidents, followed by Fire Post Impact (F-POST) and Unknown (UNK). Accidents involving aeroplanes flying intentionally low, close to the ground (coded under LALT) represent the third highest number of fatal accidents. Fewer accidents have occurred involving helicopters in Aerial Work, in comparison to aeroplanes. This is also a reflection of the smaller fleet size of helicopters registered in EASA MS. Figure 27: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered Aerial Work Helicopters, USOS ICE WSTRW RAMP TURB GCOL LOC-G UIMC MAC FUEL CTOL AMAN ARC EXTL SCF-PP UNK CFIT OTHR SCF-NP F-POST LOC-I LALT Number of Accidents Fatal accidents Non-Fatal accidents

45 PAGE 41 Other Aircraft Types During the past 5 years, accidents have also occurred in Aerial Work operations with aircraft other than Aeroplanes or Helicopters. As shown in Figure 28, a total of 33 such accidents have occurred, of which Gliders (22), and Balloons (6) are the most affected aircraft categories. Figure 28: Aerial Work Accidents by Aircraft Category and Injury Level, Involving Aircraft other than Aeroplanes or Helicopters, EASA MS State Registered, Number of Accidents Glider Balloon UAV Gyroplane Airship Aircraft category Fatal Serious Minor None

46 PAGE 42 6 General Aviation

47 PAGE 43 Introduction This chapter discusses accidents which involved aircraft of all mass categories in General Aviation operations. General Aviation means all civil aviation operations other than Commercial Air Transport or an Aerial Work operation. The aircraft are identified using the state of registry of the aircraft and categorised as either an EASA MS registered aircraft or third-country registered aircraft. Business Aviation Accidents Business Aviation is considered a subset of General Aviation operations. The data on Business Aviation are presented in this document in light of the increasing importance of this sector. The number of accidents per year involving EASA MS registered business flights has ranged between 1 and 3, an average of 1.3 per year. Figure 29: Number of Fatal Accidents in EASA MS and Third Country Registered Business Aviation Aeroplanes, Number of fatal accidents Year EASA MS registered Third Country registered EASA MS registered 3-year average Third country registered 3-year average General Aviation Accidents Above 2,250 kg MTOM This section reviews accidents involving General Aviation aircraft with a MTOM above 2,250 kg. Although all aircraft types are included in the analysis, the accidents only involved aeroplanes and helicopters, therefore there are no figures presented for other aircraft categories.

48 Annual Safety Review 2012 General Aviation PAGE 44 In Table 4 the time period presented extends from , showing the number of accidents in 2011 and 2012 as well as the average for the decade preceding these years. Table 4: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category and Operation Type, all EASA MS Registered General Aviation Aircraft Above 2,250 kg MTOM. Aircraft category Period Number of all accidents Fatal accidents Fatalities on board Ground fatalities Aeroplanes (average per year) Helicopters (average per year) Figure 30 shows the distribution of fatal accidents by aircraft category and operation type for the period Figure 30: Proportion of Fatal Accidents by Aircraft Category and Operation Type, in General Aviation Aircraft Above 2,250 kg MTOM Aeroplanes Helicopters 6% 19% 33% Pleasure Other 19% 56% Flight Training / Instructional Unknown 67% Pleasure Other Accident Categories In order to assist in the identification of particular safety issues, one or multiple occurrence categories were assigned to aeroplane and helicopter accidents involving EASA MS General Aviation operations. This was done using the CICTT occurrence categories, which are listed in Appendix 1.

49 PAGE 45 Figure 31 shows that Loss of Control In-Flight (LOC-I) is the category with the highest number of fatal accidents. The investigation in several of these accidents was not able to determine all the causes which led to the loss of control. There are several fatal accidents with the occurrence category Unknown (UNK), indicating that there was insufficient data to permit classification of these accidents. Abnormal Runway Contact (ARC) often precedes a Runway Excursion (RE): both accident categories have high numbers of non-fatal accidents. Figure 31: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered General Aviation Aeroplanes above 2,250 kg MTOM, USOS ICE F-NI ATM LOC-G TURB RAMP GCOL ARC RE SCF-NP OTHR SCF-PP FUEL CFIT UNK MAC F-POST LOC-I Number of Accidents Fatal accidents Non-Fatal accidents

50 Annual Safety Review 2012 General Aviation PAGE 46 Fewer accidents have occurred involving helicopters in General Aviation in comparison to aeroplanes. This is also a reflection of the smaller fleet size of helicopters registered in EASA MS. Figure 32: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered General Aviation Helicopters above 2,250 kg MTOM, WSTRW SCF-PP TURB SCF-NP ARC F-POST F-NI CFIT AMAN CTOL LOC-I LALT UNK Number of Accidents Fatal accidents Non-Fatal accidents

51 PAGE 47 General Aviation Accidents Below 2,250 kg MTOM Data for accidents involving aircraft not exceeding 2,250 kg MTOM was provided to EASA by the EASA MS. As in previous years, the level of reporting and the quality of the reports differs by EASA MS. Some States showed an improvement in the quality and completeness of the data and all except one of the EASA MS provided the data in an ECCAIRS. For the year 2012, one State; Liechtenstein reported zero accidents in their territory. Together, France, Germany and the UK reported 66% of all the accidents in It should be noted that the actual number of accidents may differ, as some recent accidents are possibly missing from the database while their investigation continues. Moreover, completed investigations have been added to previous years which mean that historical data is likely to be slightly different from previous Annual Safety Reviews. Table 5 presents the number of accidents, fatal accidents and fatalities in 2012 and compares them with the average for the previous period ( ). The total number of accidents decreased in 2012 when compared with the average of the previous years; globally the number of fatal accidents and fatalities on board also decreased. The decrease in fatal accidents and fatalities can mainly be seen in fewer aeroplane and helicopter accidents in spite of increase in fatal glider accidents. Table 5: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type all EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM Aircraft category Period Total number of accidents Number of fatal accidents Number of fatalities on board Number of ground fatalities Balloons Dirigibles Aeroplanes Gliders Gyroplanes Helicopters Microlights (average per year) (average per year) (average per year) (average per year) (average per year) (average per year) (average per year)

52 Annual Safety Review 2012 General Aviation PAGE 48 Aircraft category Period Other Total number of accidents Number of fatal accidents Number of fatalities on board Number of ground fatalities (average per year) Motorgliders (average per year) Average Total Total Change (%) 2012 over previous -11% -8% -5% -58% Figure 33 shows that that the number of fatal accidents in EASA MS of aircraft with MTOM below 2,250 kg has an overall slightly decreasing trend for the most common aircraft categories (Aeroplanes, Helicopters and Gliders), as shown in Figure 33. Figure 33: Number of Accidents per year, by Aircraft Category involving General Aviation Aircraft Below 2,250 kg MTOM Number of Accidents Year Aeroplane Glider Helicopter Linear (Aeroplane) Linear (Glider) Linear (Helicopter) Fatal Accidents Figure 34 shows the distribution of fatal accidents by aircraft category. The majority (42 %) of light aircraft involved in fatal accidents between 2008 and 2012 were aeroplanes. Microlight aircraft were involved in 27%, followed by gliders with 20%.

53 PAGE 49 Figure 34: Proportion of Fatal Accidents by Aircraft Category, Involving EASA MS General Aviation Aircraft Below 2,250 kg, % 2% 0% 3% 0% 20% Aeroplane Microlight Gyroplane Other Glider Balloon Helicopter Motorglider 42% 27% Accident Categories In order to assist in the identification of particular safety issues, one or multiple occurrence categories were assigned to accidents involving light aircraft. This was done using the CICTT occurrence categories, which are listed in Appendix 1. The occurrence categories had been, historically, developed to permit the tracing of the safety efforts for fixed wing air transport operations. Additional categories, more appropriate for General Aviation operation and adequate for light aircraft, rotary wing and gliders, were recently introduced and are used in this Review. These are Collision during Take-off or Landing (CTOL), Glider Towing Related Events (GTOW), Loss of Lifting Conditions En Route (LOLI) and Unintended Flight in Instrument Meteorological Conditions (UIMC). In most cases the new categories were not applied to records before As a result, the analysis may suffer from the non-uniform coding of occurrences although an effort was made to amend records where the codes were clearly missing. In previous editions of the Annual Safety Review (ASR) a general figure for all aircraft categories was presented. This figure is retained for comparison purposes, however it is recognised that the accident categories are more correctly represented if separated by the aircraft category (e.g. aeroplanes, helicopters and gliders). Note that following graphs show the total number of accidents where in the previous ASR these graphs were represented as average number of accidents per year.

54 Annual Safety Review 2012 General Aviation PAGE 50 Figure 35: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM, ATM RI-A SEC EVAC ICE RI-VAP GCOL EXTL BIRD ADRM F-NI USOS LOC-G RAMP GTOW RE LOLI WSTRW TURB ARC AMAN FUEL CTOL UIMC SCF-NP MAC OTHR SCF-PP CFIT F-POST UNK LALT LOC-I Number of Accidents Fatal accidents Non-Fatal accidents

55 PAGE 51 Figure 36: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Aeroplanes Below 2,250 kg MTOM, SEC ATM BIRD GTOW ADRM GCOL EVAC ICE RI-VAP USOS AMAN RAMP TURB LOC-G F-NI ARC WSTRW RE SCF-NP CTOL FUEL OTHR MAC UIMC SCF-PP UNK LALT CFIT F-POST LOC-I Number of Accidents Fatal accidents Non-Fatal accidents Figure 36 shows that the category assigned most frequently to fatal accidents involving aeroplanes was Loss of Control - In Flight (LOC-I). This is followed by Fire/Smoke - Post-Impact (F-POST), Controlled Flight Into Terrain (CFIT) and Low Altitude Operations (LALT) and which may have been assigned together with LOC-I. The figure also shows that there is a high number of fatal accidents involving Unintended Flight in IMC (UIMC). As this is one of the new categories and not used before 2010, the value in the graph understates its importance.

56 Annual Safety Review 2012 General Aviation PAGE 52 Figure 37: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Helicopters Below 2,250 kg MTOM, USOS RAMP EXTL ADRM WSTRW GCOL TURB LOC-G ARC F-NI MAC AMAN FUEL OTHR UIMC F-POST CFIT SCF-NP UNK CTOL LALT SCF-PP LOC-I Number of Accidents Fatal accidents Non-Fatal accidents Figure 37 shows that for helicopters LOC-I is the most important category, in terms of fatal accidents but also as the most frequent one for non-fatal accidents. The second most important is SCF-PP and third is the LALT. Figure 38 shows the occurrence categories for the aircraft category Glider. LOC-I is the most important category also for gliders, having the highest number of fatal accidents assigned. To be noted is the high incidence of Mid-Air Proximity or Collisions (MAC) for gliders compared to helicopters and aeroplanes. This may, in part, be explained by the fact that in many cases several gliders share the same area in the air, but may have difficulty in communicating with each other or being seen.

57 PAGE 53 As in previous years, exposure data for light aircraft continues to be unavailable. The number of hours flown by light aeroplanes and helicopters is not recorded by the National Aviation Authorities in the great majority of the EASA MS. Operating hours regarding gliders, balloons and aircraft such as homebuilt are also not recorded, or are, in several EASA MS, entrusted to associative organisations and not retrieved by the Authorities. Exposure Data for microlight (including microlight aeroplanes, helicopters, gyroplanes and gliders) and for Others are usually entrusted to the aircraft owner, who very seldom records or provides it. An accurate estimate of flight hours or movements is needed to allow a meaningful analysis of data and provide a measure of the safety status. Figure 38: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Gliders Below 2,250 kg MTOM, RI-A EVAC RAMP FUEL RI-VAP SCF-PP OTHR LOC-G F-POST AMAN GCOL RE USOS BIRD ADRM TURB WSTRW CTOL ARC SCF-NP GTOW LALT LOLI CFIT MAC UNK LOC-I Number of Accidents Fatal accidents Non-Fatal accidents

58 PAGE 54 7 Aerodromes

59 PAGE 55 Introduction This chapter examines accidents and serious incidents at aerodromes in EASA Member States (MS). The nature of the aviation system means that many events occur at or near an aerodrome without the aerodrome being involved. This chapter examines accidents and serious incidents that relate to the aerodrome itself or are related to a service supplied at an aerodrome. Note that data relating to Runway Incursions are presented in Chapter 8 Air Traffic Management. The time period covered in this chapter is The aerodromes included in this chapter are those which will in due course fall within the scope of EASA rules. Applicable aerodromes are those which have all of the following criteria: open to public use, serve commercial air transport, provide instrument approach or departure procedures, have a paved runway of 800 metres or above or exclusively serve helicopters. Aerodrome Accidents and Serious Incidents Aerodrome accidents and serious incidents are defined as those which involve aerodrome design or functionality issues associated with: runways, taxiways, ramp areas, parking areas, buildings and structures, fire and rescue services, obstacles on the aerodrome, lighting, markings, signage, procedures, policies, and standards. Examples include aerodrome lighting failures, ambiguous or incorrect signage and the effects of aerodrome design. In the period there were 15 accidents and serious incidents involving aerodromes. In 2012 there were no such accidents or serious incidents. Figure 39 shows the number of accidents and serious incidents per year involving aerodromes. On-going investigations into other accidents and serious incidents, as well as those shown in the graph below, may cause the data to be updated in the future so it should only be considered as preliminary data.

60 Annual Safety Review 2012 Aerodromes PAGE 56 Figure 39: Number of Accidents and Serious Incidents per Year Involving EASA MS Aerodromes Occurrences, Number of Accidents and Serious Incidents Year Serious Incident Accident The occurrence categories assigned to aerodrome accidents and serious incidents are shown in Figure 40. It can be seen that Runway Excursion (RE) is the most common occurrence category to be assigned to aerodrome accidents and serious incidents. Note that more than one occurrence category can be assigned to an occurrence. The position of System Component Failure Power Plant (SCF-PP) in aerodromes occurrences is due to two bird strikes and one case of FOD ingestion, all causing engine failures. Whether or not the engine was designed to withstand the magnitude of the bird strike or FOD ingestion is not always clear from initial occurrence reports, so all engine failures have the SCF-PP code applied. Figure 40: Occurrence Categories Assigned Alongside the Aerodrome Occurrence Category, Involving EASA Aerodromes Accidents and Serious Incidents, USOS ARC RI-A CTOL OTHR BIRD ATM GCOL LOC-G SCF-PP RE Number of Accidents and Serious Incidents

61 PAGE 57 Runway Excursions Runway Excursions are defined as when an aircraft veers off the side or overruns the end of the runway surface during take-off or landing. The European Aviation Safety Plan (EASp) identifies runway excursions as one of its five operational safety risks for Commercial Air Transport (CAT) aircraft. The issue relates to both aircraft operations, air traffic control and aerodromes. Figures for runway excursions involving CAT aeroplanes are shown in Chapter 4, figures for runway excursions at EASA MS aerodromes are shown here. In total there were 100 runway excursion accidents and serious incidents at EASA aerodromes between 2008 and of these occurred in Figure 41 shows the total number of runway excursions per year, broken down by occurrence class. Note that unlike Figure 40, the figure below includes Runway Excursions where the Aerodrome occurrence category has not been assigned, in other words the Runway Excursion did not relate to the aerodrome but more likely to factors involving aircraft operation or air traffic control. Figure 41: Number of Runway Excursion Accidents and Serious Incidents per Year at EASA Aerodromes, Number of Accidents and Serious Incidents Year Serious Incident Accident 78% of runway excursion accidents and serious incidents occurred during landing and 22% during take-off. Figure 42 shows the number of take-off and landing accidents and serious incidents.

62 Annual Safety Review 2012 Aerodromes PAGE 58 Figure 42: Number of Runway Excursions at EASA Aerodromes By Phase of Flight, Take-off Landing Number of Accidents and Serious Incidents Serious Incident Accident Ground Collisions Ground Collisions (GCOL) are defined as collisions between an aircraft and another aircraft, vehicle, person or object during taxi. The EASp identifies ground collisions as another of its five operational safety risks for commercial air transport aircraft. The number of ground collisions per year at EASA MS aerodromes is shown in Figure 43. Figures for ground collisions involving CAT aeroplanes are shown in Chapter 4, figures for ground collisions at EASA MS aerodromes are shown here. In total there were 21 ground collision accidents and serious incidents at EASA MS aerodromes between 2008 and of these occurred in Figure 43: Number of Ground Collision Accidents and Serious Incidents per Year at EASA MS Aerodromes, Number of Accidents and Serious Incidents Year Serious Incident Accident

63 PAGE 59 Ramp Accidents and Serious Incidents Ramp events are those that occur during or because of ground handling operations. Examples include loading, pushback, refuelling or de-icing errors and the ramp environment can be considered as distinct from the rest of the aerodrome environment. The number of accidents and serious incidents involving the ramp are shown in Figure 44. The most common types of ramp accident and serious incident involved collisions between aircraft and ground objects, and vehicle/equipment operations. In November 2012, a fatal ramp accident occurred when a baggage loader was killed during the turnround process. This accident has also been included in the CAT aeroplanes chapter. Figure 44: Number of Ramp Accidents and Serious Incidents per Year at EASA Aerodromes, Number of Accidents and Serious Incidents Year Serious Incident Accident Bird Strikes Although bird strikes do not always involve the aerodrome as they cannot be wholly prevented through bird management schemes, they typically occur in the aerodrome environment. The number of accidents and serious incidents involving bird strikes at or near EASA aerodromes is shown in Figure 45.

64 Annual Safety Review 2012 Aerodromes PAGE 60 Figure 45: Number of Bird Strikes per Year by Occurrence Class, Number of Accidents and Serious Incidents Year Serious Incident Accident

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66 PAGE 62 8 Air Traffic Management

67 PAGE 63 Introduction This Chapter reviews safety data for the European Air Traffic Management (ATM) system, comprising air traffic services, airspace management and air traffic flow control management. The data is provided by Eurocontrol and is collected via the Annual Summary Template (AST) mechanism. The definitions and categories used in this section therefore align with the taxonomy in use for the AST mechanism instead of the CICTT occurrence categories that are used in other parts of the Annual Safety Review. Although the AST mechanism has been in place for a number of years, there was a significant increase in reporting from 2008 onwards. For this reason, where the data is reviewed as a whole, it covers the period , whereas when a time series is shown the data covers the ten-year period The increase in reporting is observable in the rate of total occurrence reports shown in Figure 50. Note that data for 2012 is preliminary. The analysis in the ATM chapter includes accidents which occurred within an EASA MS Flight Information Region (FIR) involving at least one aircraft with MTOM of 2250 kg and above; and incidents that occurred within an EASA MS FIR with no MTOM restrictions. Accidents There were 345 ATM-related accidents in Europe between 2008 and The accidents have been categorised by the type of event they involved, as shown in Figure 46. Note that the x-axis for the other category has been shortened in order that the detail for the remaining categories is more visible. Figure 46: Number of ATM-Related Accidents in EASA MS FIRs, COL Airborne aircraft - ground aicraft or object MAC GCOL (aircraft-aircraft) CFIT GCOL (aircraft - vehicle/obstacle) Other Number of Accidents

68 Annual Safety Review 2012 Air Traffic Management PAGE 64 During the course of the investigation process for accidents, the level of ATM contribution is determined. The contribution is then categorised as either direct or indirect, as defined below: Direct Contribution where the ATM event or item was judged to be directly in the causal chain of events, Indirect Contribution where the ATM event potentially increased the level of severity. In the preliminary 2012 data, 13 accidents (5 fatal and 8 non-fatal) were reported of which 3 were indicated as having a direct ATM contribution, all non-fatal. The distribution of the 13 accidents in terms of their occurrence category is shown in Figure 47. Figure 47: Number of ATM-Contribution Accidents in EASA MS FIRs, 2012 COL Airborne aircraft - ground aircraft or object GCOL (aircraft-aircraft) MAC GCOL (aircraft - vehicle/obstacle) CFIT Other Number of Accidents Fatal Non-fatal Occurrences Occurrences are defined as accidents, serious incidents and incidents. The most common types of ATM related occurrence are: Unauthorised Airspace Penetration (UAP), Aircraft Deviation from ATC Clearance (CLR), Separation Minima Infringements (SMI), Runway Incursions (RI) and Inadequate Aircraft Separation (IS). Occurrences can be classified under more than one category, for example a CLR could lead to an SMI. The numbers of these over the period examined are shown in Figure 48, along with the severity classification applied using the Risk Analysis Tool (RAT) methodology. The severity classes are as follows: Serious Incidents (A), Major Incidents (B), Significant (C), No Safety Effect (E), and Not Determined (D).

69 PAGE 65 Figure 48: Number of ATM-related Occurrences by Occurrence Category and Severity Grade in EASA MS FIRs, IS RI SMI CLR UAP Number of Occurrences A B C E D Not classified The number of occurrences per year is shown in Figure 49, which also divides the occurrences by the contribution to the event made by ATM, as reported via the AST mechanism. It can be seen that there has been a steady increase in the number of reported occurrences over the period examined. The category that has the largest proportion of risk bearing incidents (severity A and B) is SMI. It is to be noted that this category is different from the category of IS where no minimum separation criteria have been defined. Many of the incidents that have resulted in a SMI and categorised as risk bearing are also categorised as CLR or UAP. The incident category RI has the second largest proportion of risk bearing incidents.

70 Annual Safety Review 2012 Air Traffic Management PAGE 66 Figure 49: Number of ATM-related Occurrences per Year in EASA MS FIRs, Number of Occurrences Year Not Indicated None Indirect Direct Occurrence Rates Comparing the number of incidents with the level of traffic can provide meaningful results on the safety trends. The figures in this section show two trends: The rate of incidents reported per million flight hours independent of their severity; and the rate of risk bearing incidents (severity A and B). For the incident category of Runway Incursions a rate per million aircraft movements (departures/arrivals) is being used. The rate of ATM-related occurrences per year between 2003 and 2012 is shown in Figure 50. The increase in the rate of total occurrence reports from 2008 can be clearly observed. However, the number of severity A and B reports has remained stable over the period.

71 PAGE 67 Figure 50: Rate of ATM-related Occurrences per Year in EASA MS FIRs, Rate of Severity A and B Occurrences per Million Flight Hours Rate of Occurrences per Million Flight Hours (all severity grades) Year A B Total Figure 51 shows the rate of SMIs per million flight hours. For SMIs it is useful to calculate the rate using the number of flight hours, as this best represents the timeframe during which the airspace is actually used by an aircraft. SMI s refer to occurrences in which defined minimum separation between aircraft, has been lost. Except for 2009 and 2010, the total number of incidents reported in this category has increased every year. Amongst all types of incidents, SMI s typically take the longest time to be investigated, and consequently their number may change in the future. The SMI s classified as severity A had a decreasing trend until 2010 followed by an increase in The preliminary data for 2012 indicate a small decrease in severity A occurrences. A similar increase in severity B classified SMI s was indicated in the data for 2011 and continued in 2012 now showing almost an equal level as in 2008.

72 Annual Safety Review 2012 Air Traffic Management PAGE 68 Figure 51: Rate of Separation Minima Infringements per Million Flight Hours per Year in EASA MS FIRs, Rate of SMIs per Million Flight Hours Year A B Total Figure 52 shows the rate of RIs per million flights. For RI it is useful to calculate the rate using the number of movements or flights as this represents the frequency with which a runway is being used. The European Aviation Safety Plan (EASp) identifies RI as one of its five operational safety risks for Commercial Air Transport (CAT) aircraft. Over the recent years the rate of risk bearing RI has varied. The rate of serious incidents (severity A) in 2011 indicated at almost the same level as in 2010 now shows a decrease for 2012 (based on the preliminary data reported). The rate of major incidents (severity B) decreased until 2009 and where 2010 showed an increase and 2011 indicated a reverse trend, the preliminary 2012 data indicates an increase to the same level as for Figure 52: Rate of Runway Incursions per Million Flights in EASA MS FIRs, Rate of Severity A and B RI per Million Aircraft Movements Overall rate of RI per Million Aircraft Movements Year A B Total 0

73 PAGE 69 Figure 53 shows the rate of reported UAP for the period and indicates that the overall reporting rate of this type of incident has risen considerably over the ten year period. Figure 53: Rate of Unauthorised Airspace Penetration per Million Flight Hours in EASA MS FIRs, Rate of Severity A and B UAP per Million Flight Hours Overall Rate of UAP per Million Flight Hours Year A B Total Figure 54 shows the rate of reported IS for the period It can be seen that the rate has substantially increased since 2009, indicating a possible improvement in reporting. However, the rate of major incidents (severity B) has also increased. Figure 54: Rate of Inadequate Separations per Million Flight Hours in EASA MS FIRs, Rate of Severity A and B IS per Million Flight Hours Overall Rate of IS per Million Flight Hours Year A B Total

74 Annual Safety Review 2012 Air Traffic Management PAGE 70 Figure 55 shows the rate of deviations from ATC clearances and again the increase in reporting rate is clearly observable. The rate of major incidents has also increased while the rate of serious incidents has decreased. Figure 55: Rate of Deviations from ATC Clearances per Million Flight Hours in EASA MS FIRs, Rate of Severity A and B CLR per Million Flight Hours Overall Rate of CLR per Million Flight Hours Year 0 A B Total

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76 PAGE 72 9 European Central Repository

77 PAGE 73 Introduction For over 20 years, the European Commission has been developing the concept of a centralised aviation safety data collection process, which is known as the European Coordination Centre for Accident and Incident Reporting System (ECCAIRS). Under this process, all safety occurrences from the EASA Member States (MS) are collected in a centralised database the European Central Repository (ECR). European Directive 2003/42/EC on occurrence reporting in civil aviation placed an obligation on the EU States to make all relevant safety-related information stored in their databases available to the competent authorities of other MS and the European Commission. The EASA MS were also required to make sure that their databases were compatible with the ECCAIRS software. Furthermore, according to Commission Regulation (EC) No 1321/ 2007, the EASA MS were obliged to integrated their occurrence data into the ECR. By the end of 2011, all of the EASA MS were integrating their data into the ECR. The integration of occurrences into the ECR is vital in supporting the aviation safety management work of EASA and the EASA MS because it provides the widest possible source of Pan-European safety data. The more information that is available in the ECR and the better quality of that information, the more knowledge and information that can be used by decision makers to develop the sustainable solutions required by both the aviation industry and the travelling public. Thanks to the efforts of the EASA MS the amount of information in the ECR is increasing every year and the quality of data has improved significantly over the past 2 years. This means that the vision of the ECR being a vital resource for safety analysis at European Level is becoming a more realistic prospect. This Chapter provides some key statistics concerning the safety information available in the ECR and it also provides information on how the ECR is helping to support the work of improving aviation safety in Europe. This chapter includes data from so that the changes in reporting from the beginning of the ECR to the present day are observable. The ECR at a Glance At the end of 2012 there were a total of 664,149 occurrences in the ECR. Figure 56 provides details of the occurrences in the ECR by the date of occurrence. In the early years of the ECR, between 2005 and 2009 there was a steady increase in the number of occurrences that were made available by the EASA MS. Since 2009 the number of occurrences has begun to stabilise in the region of 100,000 to 120,000 occurrences per year. The pooling of such a large number of occurrences in a single database highlights the importance of the ECR for use by EASA and the EASA MS in their analysis because it provides a far greater amount of information that would be available to any single country through their own resources. The challenge is to continually improve the quality of the data provided by the EASA MS so that it is able to provide enough detailed information to support the decision making process in its own right without the need to refer to other data or information sources. The task of continually improving data quality is part of a major effort across the European Aviation Community as part of work with European Commission (DG MOVE and the JRC), EASA, Eurocontrol and the responsible entities of the EASA MS.

78 Annual Safety Review 2012 European Central Repository PAGE 74 Figure 56: Number of Occurrences in the ECR per Year, Number of Occurrences Year of Occurrence Figure 57: Proportion of Occurrences in the ECR by Operation Type, % 1% 1% 0% Not Reported Commercial Air Transport General Aviation State Flights Unknown Aerial Work 45% 48% Figure 57 provides details of the distribution of occurrences in the ECR by operation type. In the majority of cases, 48%, this information was not reported to the ECR. However, from discussion with the Member States it is considered that the majority of these are likely involve Commercial Air Transport, which already account for 45% of the occurrences reported to the ECR. General Aviation accounted for 5% of the occurrences and State Flights were 1% of the occurrences. A smaller number of occurrences, less than 1%, involved Aerial Work.

79 PAGE 75 Figure 58: Proportion of occurrences in the ECR by Occurrence Class, % 0% 2% 1% Not Reported 9% Accident Serious Incident Incident Occurrence Without Safety Effect Not Determined 80% The distribution of occurrences in the ECR by occurrence class is provided in Figure 58. It is particularly interesting to note that only 2% of the occurrences in the ECR involves accidents, whilst 80% of the occurrences are incidents that are not normally found in other sources of data. Network of Analysts Analysis of the ECR at a European Level is carried out by the Network of Analysts (NoA), that brings together the safety analysis departments of the competent authorities with EASA, Eurocontrol and European Commission to use the information in the ECR to support safety planning activity. The NoA uses the information in the ECR with a range of other data sources to help identify the safety risks to inform the European Aviation Safety Plan (EASp). The NoA also provides a mechanism for the EASA MS to work together to improve the quality of data in the ECR. Occurrence Categories and Events in the ECR Within the ECR, there is some useful information concerning the types of occurrences and the events of the occurrences reported by the EASA MS.

80 Annual Safety Review 2012 European Central Repository PAGE 76 Figure 59: Top 10 Occurrence Categories in the ECR, RI-VAP SCF-PP SEC MAC ADRM BIRD RAMP SCF-NP ATM OTHR 0 40,000 80, ,000 Number of Occurrences Figure 59 provides details of the Top 10 occurrence categories within the ECR. The largest number of occurrences were classified as Other, which is the same situation as last year. Work has recently been carried out to analyse occurrences classified as Other and this has identified that a large number of these involve medical situations involving either crew members or passengers and a new occurrence category covering this type of occurrence will be introduced in the near future. The following most numerous occurrence categories were ATM/ CNS, System/ Component Failure - Non-Powerplant (SCF-NP), Ground Handling (RAMP) and Birdstrikes (BIRD). Figure 60: Top 5 Level 1 Event Types in the ECR, Aerodrome & ground aids Consequential events Air Navigation Services Aircraft/system/component Aircraft operation general Number of Occurrences Figure 60 provides a more detailed analysis of the occurrences in the ECR using information on the Level 1 Event Types. Critical events during an occurrence are coded using standard event types and these are captured in the chronological order in which they took place. The most numerous Event Type, Level 1, was Aircraft Operation General, followed by Aircraft/ System/ Component and Air Navigation Services.

81 PAGE 77 A more detailed analysis of the Event Types is shown in Figure 61, which has information on the Top 10 Level 2 Event Types. The most numerous Level 2 Event Type is Flight Crew/ ANS, which involves interaction between the Flight Crew of an aircraft and the Air Navigation Services. This is followed by Aircraft Collision with Obstacle/ Terrain/ Aircraft, which is often used to classify occurrences where there has been a near miss, therefore this number is not indicative of the number of actual collisions. Other Level 2 Event Types found in the Top 10 include the serviceability of ATM Systems and Aircraft Handling. Figure 61: Top 10 Level 2 Event Types in the ECR, Landing gear Aircraft - near collisions/loss of Flight crew Aerodrome services / operations Weather encounters Operational issues Aircraft handling ATM/CNS serviceability Aircraft - collisions with obstacle/ Flight crew/ans Number of Occurrences Information on the Consequential Events of occurrences in the ECR is shown in Figure 62. Consequential Events are used to describe the effects of the occurrence of the operation of the aircraft. The most often consequences of occurrences in the ECR were Aircraft Return, where the aircraft was forced to return to its original departure point following the occurrence. There were also occurrences involving Missed Approaches, Rejected Take-Offs and Diversions (where the aircraft was forced to divert from its planned destination to another airport). There were also just over 4000 occurrences were the flight crew declared an emergency.

82 Annual Safety Review 2012 European Central Repository PAGE 78 Figure 62: Top 10 Consequential Events in the ECR, Flight delay Forced landing Engine shutdown/flameout Consequential events Rejected landing Precautionary landing Declared emergency Diversion Rejected take-off Missed approach Aircraft return Number of Occurrences The number of occurrences in the ECR is continuing to grow every year and most importantly, the quality of data has improved significantly over the past few years. The information that the ECR provides, in addition to other sources of data from aircraft accidents is vital to providing the best possible knowledge of the key risks to aviation in Europe.

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84 PAGE Agency s Safety Actions

85 PAGE 81 The results of safety analysis work are combined with expert judgement, research and safety recommendations to guide the Agency s safety actions. The actions are published every year in the European Aviation Safety Plan (EASp). The EASp describes what the major risks in Europe s aviation system are and the numerous actions that are underway to mitigate them. Actions in the EASp encompass not only the work that is carried out by the Agency, but also the efforts of the EASA Member States (MS), the aviation industry and other stakeholders such as Eurocontrol, the Performance Review Body and the European Commission. This work complements what is done by the Member States to mitigate safety risks at their level. In order to provide a clear picture of the activities performed by the various safety initiatives and teams, a report on the progress made and main products developed is included with each update of the EASp. A copy of the European Aviation Safety Plan is available at

86 Appendices PAGE 82

87 PAGE 83 Appendix 1 Acronyms and Definitions Accident Aerial work (AW) ANS ASR AST ATC ATM Commercial Air Transport (CAT) CAST CICTT CNS EASA EASA MS EASp ECCAIRS EC ECR An occurrence associated with the operation of an aircraft, which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which: a) a person suffers a fatal or serious injury as a result of: being in or upon the aircraft; direct contact with any part of the aircraft, including parts which have become detached from the aircraft; or direct exposure to jet blast; except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or b) the aircraft sustains damage or structural failure which: adversely affects the structural strength, performance or flight characteristics of the aircraft; and would normally require major repair or replacement of the affected component; except for engine failure or damage, when the damage is limited to the engine, its cowlings or accessories; or for damage limited to propellers, wing tips, antennas, tyres, brakes, fairings, small dents or puncture holes in the aircraft skin; or c) the aircraft is missing or is completely inaccessible. Source: ICAO Annex 13 An aircraft operation in which an aircraft is used for specialised services such as agriculture, construction, photography, surveying, observation and patrol, search and rescue, or aerial advertisement. Air Navigation Services EASA Annual Safety Review Annual Summary Template Air Traffic Control Air Traffic Management An aircraft operation involving the transport of passengers, cargo or mail for remuneration or hire. Commerical Aviation Safety Team CAST-ICAO Common Taxonomy Team Communications, Navigations and Surveillance European Aviation Safety Agency European Aviation Safety Agency Member States. These States are the 27 European Union Member States plus Iceland, Liechtenstein, Norway and Switzerland. European Aviation Safety Plan European Co-Ordination Centre for Aviation Incident Reporting Systems European Commission European Central Repository for occurrences

88 Annual Safety Review 2012 Appendices PAGE 84 EU Fatal Accident Fatal Injury FIR FOD General Aviation (GA) HEMS ICAO IFR Light Aircraft MTOM NAA Off-shore Occurrence Scheduled air service Serious Incident Serious Injury SMS Third country operated aircraft European Union An accident that resulted in at least one fatality, flight crew and/or passenger or on the ground, within 30 days of the accident. Source: ICAO Annex 13 An injury which is sustained by a person in an accident and which results in his death within 30 days of the date of the accident. Source: ICAO Annex 13 Flight Information Region Foreign Object Debris An aircraft operation other than a commercial air transport operation or an aerial work operation. Helicopter Emergency Medical Service International Civil Aviation Organisation Instrument Flight Rules Aircraft with a maximum certificated take-off mass below kg. Maximum certificated take-off mass National Aviation Authorities An off-shore operation is an aircraft flight to a landing site off the coast, for example an oil or gas platform. Note, this should not be confused with off-shore in the sense of outside territorial waters. An accident, serious incident or incident An air service open to use by the general public and operated according to a published timetable or with such a regular frequency that it constitutes an easily recognisable systematic series of flights which are open to direct booking by members of the public. An incident involving circumstances indicating that an accident nearly occurred. An injury which is sustained by a person in an accident and which: a) requires hospitalisation for more than 48 hours, commencing within seven days from the date the injury was received; b) results in a fracture of any bone (except simple fractures of fingers, toes or nose); c) involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage; d) involves injury to any internal organ; e) involves second or third degree burns, or any burns affecting more than 5 per cent of the body surface; or f) involves verified exposure to infectious substances or harmful radiation. Safety Management System An aircraft which is not used or operated under control of a competent authority of an EASA Member State.

89 PAGE 85 Occurrence Categories: Occurrence categories can be used to classify occurrence at a high level to permit analysis of the data. The CICTT has developed the occurrence categories used in this Annual Safety Review. For further details on this team and the occurrence categories see the website ( ARC AMAN ADRM ATM/CNS BIRD CABIN CFIT CTOL EVAC EXTL F-NI F-POST FUEL GCOL GTOW RAMP ICE LOC-G LOC-I LOLI LALT MAC OTHR RE RI-A RI-VAP SEC SCF-NP SCF-PP TURB UIMC USOS UNK WSTRW Abnormal runway contact Abrupt manoeuvre Aerodrome Air Traffic Management/Communication Navigation Surveillance Collision / near Collision with bird(s) Cabin safety event Controlled flight into or toward terrain Collision with obstacle(s) during take-off and landing Evacuation External load related occurrence Fire/smoke (non-impact) Fire/smoke (post-impact) Fuel related Ground collision Glider towing related event Ground handling Icing Loss of control Ground Loss of control In-flight Loss of lifting conditions en-route Low altitude operation Airprox/TCAS alert/loss of separation/near midair collisions/midair collision Other Runway excursion Runway incursion Animal Runway incursion Vehicle, aircraft or person Security related System/component failure or malfunction (non-powerplant) System/component failure or malfunction (powerplant) Turbulence encounter Unintended Flight in IMC Undershoot/overshoot Unknown or undetermined Windshear or thunderstorm

90 Annual Safety Review 2012 Appendices PAGE 86 ATM Accident Categories Acronyms CLR IS MAC SMI UAP RI COL Deviation of ATC Clearance Inadequate Separation Mid-Air Collision Separation Minima Infringement Unauthorised Penetration of Airspace Runway Incursion is an occurrence involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for the landing and take-off of aircraft. Collision with a vehicle, person or aircraft, while an aircraft is on the ground

91 PAGE 87 Appendix 2 List of Figures and Tables List of Figures Number of Fatal Accidents Involving EASA MS and Third Country Operated CAT Aeroplanes, MTOM Above 2,250 kg, interior cover Proportion of Fatal accidents by Aircraft Category Accidents in EASA MS Involving General Aviation Aircraft Below 2,250 kg, interior cover Number of Fatal Accidents involving, EASA MS and Third Country Operated CAT Helicopters, MTOM Above 2,250 Kg, interior cover Figure 1: Number and Rate per Million Flights of Scheduled Passenger and Cargo Fatal Accidents Worldwide per Year, Figure 2: Rate of Scheduled Passenger and Cargo Fatal Accidents, per Million Flights by World Region, Figure 3: Number of IFR Flights in EASA MS per Year, Figure 4: Number of IFR Flights in EASA MS per Year by Market Segment, Figure 5: Proportion of Flights in Each Market Segment, Figure 6: Number of EASA MS Registered Aircraft Filing Flight Plans, Figure 7: Number of EASA MS Registered Aircraft Filing Flight Plans by Aircraft Category, Figure 8: Number of EASA MS Registered Aircraft Filing Flight Plans by Aircraft Mass Category, Figure 9: Number of Passengers Carried Per Year in EASA MS, Figure 10: Tonnes of Cargo Carried per Year in EASA MS, Figure 11: Number of Passengers Carried per Country, Figure 12: Tonnes of Cargo Transported per Country, Figure 13: Number of Fatal Accidents in EASA MS and Third Country Operated CAT Aeroplanes, MTOM Above 2,250 kg, Figure 14: Rate of Fatal Accidents in EASA MS and Third Country Scheduled Passenger Operations, Aeroplanes Above 2,250 kg MTOM, Figure 15: Proportion of Fatal Accidents by Aircraft Mass Category, EASA MS Operated CAT Aeroplanes above 2,250 kg MTOM,

92 Annual Safety Review 2012 Appendices PAGE 88 Figure 16: Proportion of Fatal Accidents by Aircraft Mass Category, Third Country Operated CAT Aeroplanes above 2,250 kg MTOM, Figure 17: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS CAT Aeroplanes above 2,250 kg MTOM, Figure 18: Number of Fatal Accidents in EASA MS and Third Country Operated CAT Helicopters, Above 2,250 kg MTOM Figure 19: Proportion of Injury Levels for Accidents in EASA MS Operated CAT Helicopters, All Mass Categories, Figure 20: Number of Accidents by Operation Type, EASA MS Operated CAT Helicopters, All Mass Categories, Figure 21: Proportion of Fatal Accidents and Fatalities in Off-Shore and Non Off-Shore Operations, EASA MS Operated CAT Helicopters, All Mass Categories, Figure 22: Occurrence Categories for Fatal and Non-Fatal Accidents EASA MS Operated CAT Helicopters, All Mass Categories, Figure 23: Top 5 Occurrence Categories of Fatal and Non-Fatal Accidents in Helicopters Above and Below 2,250 kg MTOM, Figure 24: Number of Accidents Involving EASA MS Registered Balloon CAT, Figure 25: Fatal Accidents by Aircraft Category and Operation Type in Aerial Work, All Mass Categories, Figure 26: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered Aerial Work Aeroplanes, Figure 27: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered Aerial Work Helicopters, Figure 28: Aerial Work Accidents by Aircraft Category and Injury Level, Involving Aircraft other than Aeroplanes or Helicopters, EASA MS State Registered, Figure 29: Number of Fatal Accidents in EASA MS and Third Country Registered Business Aviation Aeroplanes, Figure 30: Proportion of Fatal Accidents by Aircraft Category and Operation Type, in General Aviation Aircraft Above 2,250 kg MTOM Figure 31: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered General Aviation Aeroplanes above 2,250 kg MTOM, Figure 32: Occurrence Categories for Fatal and Non-Fatal Accidents in EASA MS Registered General Aviation Helicopters above 2,250 kg MTOM,

93 PAGE 89 Figure 33: Number of Accidents per year, by Aircraft Category involving General Aviation Aircraft Below 2,250 kg MTOM Figure 34: Proportion of Fatal Accidents by Aircraft Category, Involving EASA MS General Aviation Aircraft Below 2,250 kg, Figure 35: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM, Figure 36: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Aeroplanes Below 2,250 kg MTOM, Figure 37: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Helicopters Below 2,250 kg MTOM, Figure 38: Occurrence Categories for Fatal and Non-Fatal Accidents - EASA MS Registered General Aviation Gliders Below 2,250 kg MTOM, Figure 39: Number of Accidents and Serious Incidents per Year Involving EASA MS Aerodromes Occurrences, Figure 40: Occurrence Categories Assigned Alongside the Aerodrome Occurrence Category, Involving EASA Aerodromes Accidents and Serious Incidents, Figure 41: Number of Runway Excursion Accidents and Serious Incidents per Year at EASA Aerodromes, Figure 42: Number of Runway Excursions at EASA Aerodromes By Phase of Flight, Figure 43: Number of Ground Collision Accidents and Serious Incidents per Year at EASA MS Aerodromes, Figure 44: Number of Ramp Accidents and Serious Incidents per Year at EASA Aerodromes, Figure 45: Number of Bird Strikes per Year by Occurrence Class, Figure 46: Number of ATM-Related Accidents in EASA MS FIRs, Figure 47: Number of ATM-Contribution Accidents in EASA MS FIRs, Figure 48: Number of ATM-related Occurrences by Occurrence Category and Severity Grade in EASA MS FIRs, Figure 49: Number of ATM-related Occurrences per Year in EASA MS FIRs, Figure 50: Rate of ATM-related Occurrences per Year in EASA MS FIRs, Figure 51: Rate of Separation Minima Infringements per Million Flight Hours per Year in EASA MS FIRs,

94 Annual Safety Review 2012 Appendices PAGE 90 Figure 52: Rate of Runway Incursions per Million Flights in EASA MS FIRs, Figure 53: Rate of Unauthorised Airspace Penetration per Million Flight Hours in EASA MS FIRs, Figure 54: Rate of Inadequate Separations per Million Flight Hours in EASA MS FIRs, Figure 55: Rate of Deviations from ATC Clearances per Million Flight Hours in EASA MS FIRs, Figure 56: Number of Occurrences in the ECR per Year, Figure 57: Proportion of Occurrences in the ECR by Operation Type, Figure 58: Proportion of occurrences in the ECR by Occurrence Class, Figure 59: Top 10 Occurrence Categories in the ECR, Figure 60: Top 5 Level 1 Event Types in the ECR, Figure 61: Top 10 Level 2 Event Types in the ECR, List of Tables Overview of the Number of Commercial Air Transport Accidents, Fatal Accidents and Fatalities for EASA MS Operated Aircraft above 2,250 kg MTOM...interior cover Overview of the Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type All EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM...interior cover Table 1: Overview of Total Number of Accidents, Fatal Accidents and Fatalities for EASA MS Operated Aeroplanes, above 2,250 kg MTOM Table 2: Overview of Total Number of Accidents, Fatal Accidents and Fatalities for EASA MS Operated Helicopters, All Mass Categories Table 3: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type, All Mass Categories, All EASA MS Registered Aerial Work Aircraft Table 4: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category and Operation Type, all EASA MS Registered General Aviation Aircraft Above 2,250 kg MTOM Table 5: Overview of Number of Accidents, Fatal Accidents and Fatalities by Aircraft Category And Operation Type all EASA MS Registered General Aviation Aircraft Below 2,250 kg MTOM... 47

95 PAGE 91 Appendix 3 List of Fatal Accidents in 2012 This list only includes worldwide fatal accidents involving commercial air transport aeroplanes with a maximum take-off mass above 2,250 kg Local Date State of Occurrence Aircraft Type Operation Type Fatalities on Board Ground Fatalities Occurrence Categories 30/01/2012 DR Congo ANTONOV AN-28 Cargo 3 0 UNK: Unknown or undetermined 16/02/2012 Brazil BEECH 55 Passenger 4 0 UNK: Unknown or undetermined CTOL: Collision with obstacle(s) during take-off and landing 28/02/2012 Brazil CESSNA 208 Ferry/ positioning 1 0 UNK: Unknown or undetermined CTOL: Collision with obstacle(s) during take-off and landing 01/03/2012 Chile PIPER PA-31 Passenger 7 0 UNK: Unknown or undetermined 15/03/2012 Puerto Rico CONVAIR 440 Cargo 2 0 SCF-PP: powerplant failure or malfunction 02/04/2012 Russian Federation ATR Passenger 31 0 ICE: Icing, LOC-I: Loss of control - inflight 08/04/2012 Indonesia DE HAVILLAND DHCG-300 Passenger 1 0 GCOL: Ground Collision EC: Security related 20/04/2012 Pakistan BOEING Passenger CFIT: Controlled flight into or toward terrain F-POST: Fire/smoke (post-impact) 21/04/2012 Bolivia CURTISS WRIGHT C46 Cargo 3 0 UNK: Unknown or undetermined 14/05/2012 Nepal HINDUSTAN Passenger 15 0 CTOL: Collision with obstacle(s) during take-off and landing RE: Runway excursion 02/06/2012 Ghana BOEING Cargo 0 12 UNK: Unknown or undetermined CTOL: Collision with obstacle(s) during take-off and landing 03/06/2012 Nigeria DOUGLAS DC9-80 Passenger SCF-PP: powerplant failure or malfunction CTOL: Collision with obstacle(s) during take-off and landing 06/06/2012 Uruguay SWEARINGEN SA-227 Cargo 2 0 UNK: Unknown or undetermined 22/06/2012 United States BEECH 90 Ferry/ positioning 1 0 CFIT: Controlled flight into or toward terrain 07/07/2012 United States BEECH 90 Ferry/ positioning 1 0 WSTRW: Windshear or thunderstorm.

96 Annual Safety Review 2012 Appendices PAGE 92 Local Date State of Occurrence 19/08/2012 Sudan Aircraft Type ANTONOV AN-26 Operation Type Fatalities on Board Passenger 32 0 Ground Fatalities Occurrence Categories CFIT: Controlled flight into or toward terrain UNK: Unknown or undetermined 22/08/2012 Kenya LET L410 Passenger 4 0 UNK: Unknown or undetermined 12/09/2012 Russian Federation ANTONOV AN-28 Passenger 10 0 UNK: Unknown or undetermined 28/09/2012 Nepal DORNIER Passenger 19 0 BIRD: Birdstrike 07/10/2012 Antigua and Barbuda BRITTEN NORMAN BN2A-26 Passenger 2 0 RE: Runway excursion UNK: Unknown or undetermined 07/10/2012 Arkansas GRUMMAN G44 Ferry/ positioning 1 0 CTOL: Collision with obstacle(s) during take-off and landing 07/10/2012 Sudan ANTONOV AN-12 Cargo 15 0 SCF-PP: powerplant failure or malfunction 06/11/2012 United States CESSNA 208 Cargo 1 0 SCF-PP: powerplant failure or malfunction CTOL: Collision with obstacle(s) during take-off and landing 11/11/2012 Italy AIRBUS A320 Passenger 0 1 RAMP: Ground Handling 30/11/2012 DR Congo ILYUSHIN IL-76 Cargo 7 25 CTOL: Collision with obstacle(s) during take-off and landing 17/12/2012 Peru 22/12/2012 Canada ANTONOV AN-26 SWEARINGEN SA-227 Cargo 4 0 UNK: Unknown or undetermined Passenger 1 0 RE: Runway excursion 25/12/2012 Myanmar FOKKER F28 Passenger 1 1 CTOL: Collision with obstacle(s) during take-off and landing 29/12/2012 Russian Federation TUPOLEV TU Ferry/ positioning 5 0 RE: Runway excursion

97 EASA Annual Safety Review 2012 Luxembourg: Publications Office of the European Union pp cm ISSN doi: /50178 ISBN

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103 European Aviation Safety Agency Safety Analysis & Research Department Postal address Postfach Cologne Germany Visiting address Ottoplatz Cologne Germany Tel Fax Mail info@easa.europa.eu Web